THIS FORM IS FOR CASUAL PATIENTS ONLY.

If you already attend Burwood Health, please use the Enrolled Patient form.

CASUAL PATIENTS - Travel Questionnaire

The information on this form will help our team identify the vaccines you may require for overseas travel. Please complete a separate questionnaire for every person travelling, including any children. A nurse will contact you with 5 business days.

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PERSONAL INFORMATION

Name(Required)

First Last

Address:(Required)

Date of Birth(Required)

Email Address(Required)

Phone(Required)

TRAVEL DETAILS

Departure Date(Required)

DD slash MM slash YYYY

Return Date(Required)

DD slash MM slash YYYY

Who are you travelling with?(Required)

Purpose of your travel (ie. holiday, business, volunteer work, visiting friends and relatives, special high risk activities)(Required)

Are your travel plans booked yet? (ie. flights, accommodation, transfers, activities)(Required)

Destinations(Required)

Country

Town / Region

Urban / Rural

Accommodation

Duration

MEDICAL HISTORY

Medical History (Please list)(Required)

Are you up to date with your childhood vaccinations?(Required)

Yes

Unsure

Please give details of any conditions that may affect your travel plans (Pregnancy, Diabetes, Disability, Immunocompromised, Heart Condition, Blood Clots, Thymus or Spleen problems, HIV/AIDS or recent surgery:(Required)

Allergies (ie. Eggs, Antibiotics etc)(Required)

Current Medications (including oral contraceptives):(Required)

WOMEN ONLY - Are you pregnant, planning pregnancy or breast feeding? If relevant, the number of weeks pregnant at time of travel

PREVIOUS TRAVEL HISTORY

Have you had previous travel vaccines?

Yes

Please give details of any previous vaccinations and anti-malarial medications below:

BCG

Date Recieved

Comments (ie. side effects)

Cholera

Date Recieved

Comments (ie. side effects)

Covid-19

Date Recieved

Comments (ie. side effects)

Hepatitis A

Date Recieved

Comments (ie. side effects)

Hepatitis B

Date Recieved

Comments (ie. side effects)

Influenza

Date Recieved

Comments (ie. side effects)

Japanese Encephalitis

Date Recieved

Comments (ie. side effects)

Meningococcal Group A, C, Y, W

Date Recieved

Comments (ie. side effects)

Meningococcal Group B

Date Recieved

Comments (ie. side effects)

Meningococcal Group C

Date Recieved

Comments (ie. side effects)

Pneumococcal

Date Recieved

Comments (ie. side effects)

Polio

Date Recieved

Comments (ie. side effects)

Rabies

Date Recieved

Comments (ie. side effects)

Tetanus alone

Date Recieved

Comments (ie. side effects)

Tetanus, Diphtheria, Pertussis

Date Recieved

Comments (ie. side effects)

Tetanus, Diphtheria, Pertussis, Polio

Date Recieved

Comments (ie. side effects)

Typhoid

Date Recieved

Comments (ie. side effects)

Yellow Fever

Date Recieved

Comments (ie. side effects)

Other

Date Recieved

Comments (ie. side effects)

Anti-Malarial Medications

Date Recieved

Comments (ie. side effects)

REQUESTED TRAVEL VACCINATIONS

PLEASE CHOOSE ONE OF THE FOLLOWING OPTIONS

CASUAL PATIENT - I will only have the vaccinations I tick below and am aware that I will not have a GP consultation ($135 + Vaccinations)

CASUAL PATIENT - I will require advice on what vaccinations I require for my travel ($135 + Vaccinations)

I require the following vaccinations:

Avaxim $125

Chicken Pox $110 per dose (2 DOSES REQUIRED)

Cholera (Dukoral) $100 per dose (2 DOSES REQUIRED)

Hepatitis A (Adult Dose) $135

Hepatitis A (Junior) $95

Hepatitis A & B (Adult Dose) $125 per dose (3 DOSES REQUIRED)

Hepatitis A & B (Junior) $95 per dose (3 DOSES REQUIRED)

Hepatitis B $90 per dose (3 DOSES REQUIRED)

Hepatitis A / Typhoid $235

HPV (Gardasil -9) $340 per dose (3 DOSES REQUIRED)

Flu Vaccine $30

Fluad Quad (Superflu) $40

Japanese Encephalitis $270 per dose (2 DOSES REQUIRED)

Meningitis ACYW (Menactra / Nimenrix) $180

Meningitis B (Bexsero) $200 per dose (2 DOSES REQURIRED)

Meningitis C $105

Measles / Mumps / Rubella $50

Pneumococcal: Pneumovax $130

Pneumococcal: Prevenar 13 $260

Polio $110

Rabies (Rabipur) Intramuscular (Rabies) $240 per dose (3 DOSES REQUIRED)

Shingles $500 per dose (2 DOSES REQUIRED)

Tetanus / Diphtheria / Pertussis (Boostrix) $70

Tetanus / Diphtheria / Pertussis / Polio $ 120

Typhoid $125

Do you require information on any of the following:

Bite and sting avoidance

Food and water safety

Sexual health advice

Other

PRE-PAYMENT CONSENT

PRE-PAYMENT - I am aware that I will receive an invoice that will require payment before my travel vaccination request is processed and reviewed by a Health Provider at Burwood Health(Required)

I AGREE TO THE $135 PRE-PAYMENT - I AM AWARE THTA DOES NOT INCLUDE THE COST OF MY TRAVEL VACCINATIONS

ANTI-MALARIAL MEDICATIONS

I am aware that as a CASUAL PATIENT I am unable to enquire about Anti-Malarial medication. I am aware that I will need to see my own GP for this information.(Required)

I am aware I am unable to enquire about Anti-Malarial medications

APPOINTMENT AT BURWOOD HEALTH

I am aware that as a CASUAL PATIENT I will not be able to have a GP appointment at Burwood Health(Required)

I am aware that I cannot have a GP appointment at Burwood Health

CONSENT AS A CASUAL PATIENT

Consent(Required)

I certify that the answers I have provided are true to my knowledge, and the advice and vaccination recommendations I receive will be influence by the answers I have provided. I am aware that I may need to remain in the clinics for 20 minutes after the vaccinations.

Casual Patient Consent(Required)

I consent that I am aware that I am a CASUAL patient of Burwood Health and I am not enrolling with the practice. I will only be discussing Travel Vaccination information with the practice and no other medical requirements. I understand that I will need to pre-pay for my appointment and vaccinations. I also understand that I will be required to speak to my own General Practitioner about any Anti-Malarial advice and medications and that Burwood Health is unable to assist me with this.

FINANCIAL CONSENT

Financial Consent(Required)

I consent that I understand that the cost of the vaccinations recommended are additional to the cost of the consultation. I am also aware that I will need to pre-pay for both my travel vaccination consult and the recommended travel vaccinations.

Burwood Health

(03) 383 0219

Casual Patients – Travel Questionnaire

THIS FORM IS FOR CASUAL PATIENTS ONLY.

CASUAL PATIENTS - Travel Questionnaire

PERSONAL INFORMATION

TRAVEL DETAILS

MEDICAL HISTORY

PREVIOUS TRAVEL HISTORY

Please give details of any previous vaccinations and anti-malarial medications below:

REQUESTED TRAVEL VACCINATIONS

PRE-PAYMENT CONSENT

ANTI-MALARIAL MEDICATIONS

APPOINTMENT AT BURWOOD HEALTH

CONSENT AS A CASUAL PATIENT

FINANCIAL CONSENT

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